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Unlike Diamonds, Defibrillators Aren’t Forever: Why It Is Sometimes Ethical to Deactivate Cardiac Implantable Electrical Devices

  • DANIEL P. SULMASY and MARIELE A. COURTOIS

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Acknowledgements: Mariele Courtois thanks the Notre Dame Center for Ethics and Culture for its sponsorship of her internship with Dr. Sulmasy at the MacLean Center for Clinical Medical Ethics in the summer of 2016.

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Notes

1. Brock, DW. Taking human life. Ethics 1985;95(4):851–65.

2. Arguments for and against a distinction between assisted suicide and treatment withdrawal are discussed in Miller FG, Fins JJ, Snyder L. Assisted suicide compared with refusal of treatment: a valid distinction? University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel. Annals of Internal Medicine 2000;132(6):470–5.

3. Rachels, J. Active and passive Euthanasia. New England Journal of Medicine 1975;292:7880.

4. Huddle, TS. A moral argument against turning off an implantable cardiac device: Why deactivation is a form of killing, not simply allowing a patient to die. Cambridge Quarterly of Healthcare Ethics 2019;28(2): 329337, at 332.

5. See note 4, Huddle 2019, at 330, 333.

6. See note 4, Huddle 2019, at 334–5.

7. See note 4, Huddle 2019, at 334–5.

8. Sulmasy, DP. Killing and Allowing to Die: Taking Another Look. Journal of Law, Medicine & Ethics 1998;26(1):5564.

9. Mueller, PS, Swetz, KM, Freeman, MR, Carter, KA, Crowley, ME, Severson, CJA, et al. Ethical Analysis of Withdrawing Ventricular Assist Device Support. Mayo Clinic Proceedings 2010.

10. See note 8, Sulmasy 1998.

11. See note 8, Sulmasy 1998.

12. See note 9, Mueller et al. 2010.

13. See note 8, Sulmasy 1998.

14. See note 9, Mueller et al. 2010.

15. See note 8, Sulmasy 1998.

16. According to Huddle, a physician should not interfere with a completed therapy that is disengaged from physician agency and puts the patient at a physiological equilibrium; an “ongoing” therapy, which continually requires maintenance or intervention by a physician in order to properly and beneficially function, may be deactivated as desired by the patient because it is not independently sustained. See note 4, Huddle 2019, at 334–5.

17. Fuchs, ME, Anderson, RE, Ostrowski, KA, Brant, WO, Fuchs, EF. Pre-operative risk factors associated with need for vasoepididymostomy at the time of vasectomy reversal. Andrology 2016;4(1):160–2.

18. Polackwich, AS, Tadros, NN, Ostrowski, KA, Kent, J, Conlin, MJ, Hedges, JC, Fuchs, EF. Vasectomy reversal for postvasectomy pain syndrome: A study and literature review. Urology 2015;86(2):269–72.

19. Dickey, RM, Pastuszak, AW, Hakky, TS, Chandrashekar, A, Ramasamy, R, Lipshultz, L. The evolution of vasectomy reversal. Current Urology Reports 2015;16(6):40.

20. Montgomery, A, Kallinowski, F, Kockerling, A. Evidence for replacement of an infected synthetic by a biological mesh in abdominal wall hernia repair. Frontiers in Surgery 2015;2:67.

21. Narita, M, Moriyoshi, K, Hanada, K, Matsusue, R, Hata, H, Yamaguchi, T, et al. Successful treatment for patients with chronic orchialgia following inguinal hernia repair by means of meshoma removal, orchiectomy and triple-neurectomy. International Journal of Surgery Case Reports 2015;16:157–61.

22. Wong, SH, Eldridge, PR, Duffy, A, Fox, SH, Varma, TRK, Fletcher, NA. Two cases of unexpected long-term improvement of Parkinson’s disease after subthalamic nucleus deep brain stimulation removal. British Journal of Neurosurgery 2011;25(2):281–3.

23. Fenoy, AJ, Simpson, RK Jr. Management of device-related wound complications in deep brain stimulation surgery. Journal of Neurosurgery 2012;116(6):1324–32.

24. Bulluss, KJ, Pereira, EA, Joint, C, Aziz, TZ. Pallidotomy after chronic deep brain stimulation. Neurosurgical Focus 2013;35(5):E5.

25. Vergani, F, Landi, A, Pirillo, D, Cilia, R, Antonini, A, Sganzerla, EP. Surgical, medical, and hardware adverse events in a series of 141 patients undergoing subthalamic deep brain stimulation for Parkinson disease. World Neurosurgery 2010;73(4):338–44.

26. Nigim, F, Critchlow, JF, Kasper, EM. Role of ventriculoperitoneal shunting in patients with neoplasms of the central nervous system: An analysis of 59 cases. Molecular and Clinical Oncology 2015;3(6):1381–6.

27. Al-Holou, WN, Sack, JA, Garton, HJ, Muraszko, KM, Maher, CO. Removal of ventricular shunts. Pediatric Neurosurgery 2010;46(3):172–6.

28. Pham, U, Solbakk, AK, Skogseid, IM, Toft, M, Pripp, AH, Konglund, AE, Andersson, S, Haraldsen, IR, Aarsland, D, Dietrichs, E, Malt, UF. Personality changes after deep brain stimulation in Parkinson’s disease. Parkinson’s Disease 2015;2015:490507.

29. Castrioto, A, Lhommée, E, Moro, E, Krack, P. Mood and behavioural effects of subthalamic stimulation in Parkinson’s disease. Lancet Neurology 2014;13(3):287305.

30. See note 26, Nigim et al. 2015.

31. Schreffler, RT, Schreffler, AJ, Wittler, RR. Treatment of cerebrospinal fluid shunt infections: a decision analysis. Pediatric Infectious Disease Journal 2002;21(7):632–6.

32. Vajramani, GV, Jones, G, Bayston, R, Gray, WP. Persistent and intractable ventriculitis due to retained ventricular catheters. British Journal of Neurosurgery 2005;19(6):496501.

33. It is also important to note that there are no legal reasons for continuing treatments. See note 9, Mueller et al. 2010.

34. Sulmasy, DP. Within You / Without You: Biotechnology, ontology, and ethics. Journal of General Internal Medicine. 2008;23(Suppl. 1):6972.

35. Huddle seems to acknowledge this feature of CIEDs, but fails to capture all of its implications within the small scope that is attached to a “completed therapy” category. He writes, “…the pacemaker itself is acting less like a finger in the hold of the dike (analogous to a ventilator arresting lethal respiratory pathophysiology) and more like a repair of the dike.” See note 4, Huddle 2019, at 332.

36. See note 34, Sulmasy 2008.

37. See note 34, Sulmasy 2008, at 71.

38. This addresses the concern raised by Huddle (note 1, Huddle 2019, at 332), that “Sulmasy’s analysis seems powerless to resolve this disagreement because whether a new pathophysiology has been introduced, the distinguishing criterion of killing in Sulmasy’s scheme, is what is at issue in the disagreement—a disagreement not over natural facts but over the appropriate description of those facts.” This is because Huddle founds his critique solely upon Sulmasy’s basic analysis of the K/ATD distinction (note 8, Sulmasy 1998) and ignores Sulmasy’s application of this basic analysis to emerging technologies. See note 34 2008.

39. See note 4, Huddle 2019, at 333.

40. See note 34, Sulmasy 2008.

41. See note 34, Sulmasy 2008.

42. See note 4, Huddle 2019, at 334.

43. Though this is not to say that all instances of removal (as opposed to deactivation) are illicit. Under appropriate circumstances, a substitutive therapy can also be removed from the body just as licitly as another (or the same) substitutive therapy can be turned off.

44. It is true that the degree to which a physician is involved as an agent in the care of the patient can imply the severity of the patient’s case, as indicated by Huddle: “That is, if physician agency in a treatment is ongoing, as in hemodialysis or mechanical ventilation, the physician is judging the patient to be in an arrested downward trajectory, and it is sometimes permissible for physicians to withdraw their agency and allow the patient to die. If a treatment is independent of physician agency (or to the degree that it is), the patient is judged to be in equilibrium.” But the term “completed” may conflate agency status with treatment status, as it intrinsically is a descriptor of the physician’s relationship to the treatment, not of the natural facts of the treatment itself. Quote from: See note 4, Huddle 2019, at 333.

45. See note 4, Huddle 2019, at 333.

46. See note 9, Mueller et al. 2010.

47. Bramstedt, KA. Destination nowhere: a potential dilemma with ventricular assist devices. American Society for Artificial Internal Organs Journal 2008;54(1):12.

48. McMahan, J. Killing, Letting Die, and Withdrawing Aid. Ethics 1993;103:250–79. Referenced in: See note 4, Huddle 2019, at 333–4.

49. See note 4, Huddle 2019, at 334.

50. See note 4, Huddle 2019, at 334.

51. “…some ethicists argue that withdrawing is often morally preferable to withholding in cases where one needs time to determine whether or not the therapy is effective.” Sulmasy DP, Sugarman J. Are withholding and withdrawing therapy always morally equivalent? Journal of Medical Ethics 1994;20:218–22.

Acknowledgements: Mariele Courtois thanks the Notre Dame Center for Ethics and Culture for its sponsorship of her internship with Dr. Sulmasy at the MacLean Center for Clinical Medical Ethics in the summer of 2016.

Unlike Diamonds, Defibrillators Aren’t Forever: Why It Is Sometimes Ethical to Deactivate Cardiac Implantable Electrical Devices

  • DANIEL P. SULMASY and MARIELE A. COURTOIS

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